Nominee Information Name Title Company Address Work Phone Home Phone Email Have you alerted your nominee that she has been nominated by you? Yes           No Will your nominee be able to personally attend the event in New York on April 13 if selected? Yes           No Your Information Name Title Company Address Work Phone Home Phone Email Relationship to nominee (check all that apply) Self Family Friend Work Colleague Client Do not know personally Beyond the facts listed above, please state if there is other supporting factual business information that will help the judges understand why this woman is a true agent of change (250 words or less): Nomination Category select only one* Quantum Leap 15 years or more professional experience The edgy breakthrough move by a woman who has taken a risk by spurring change in her organization Paradigm Shift 15 years or more professional experience The woman who saw an opportunity to think differently about a consumer market Brainwave 15 years or more professional experience The woman behind an innovative improvement in her industry No Apologies 5 years or more professional experience The woman behind the product or idea that made the lives of people easier, more fun, interesting or better in some way * AWNY reserves the right to change the category classification as determined by the judging criteria. Nomination Statement Please list three factual and specific business statements from within the last 2 years that support this nomination. For example: 1) Restructured her organization to meet the needs of the Hispanic market 2) Increased sales by 23% by developing a new market segment for her product 3) Invented a new online site for women who job share that now has 520,000 members 1) 2) 3) Certification By submitting this nomination I hereby attest that, to the best of my knowledge, all the information contained herein is accurate and factual and can be corroborated by the nominee. Accept           Decline Digital Signature type in your name Date